Medicaid

Yesterday, Strategic Behavioral Health (SBH) announced plans for a psychiatric hospital in the Madison area to open by late summer 2019. It would provide 72 beds, cost $15 to 20 million, and offer inpatient and outpatient services.

According to county officials, the hospital would meet the long-established need for an alternative to a trip to Winnebago State Hospital for persons suffering from a psychotic episode and the police who accompany them. It would also provide many of the services offered by a crisis restoration center. Click here to read David Wahlberg’s article in the Wisconsin State Journal.

SBH has an entrepreneurial and ambitious approach to mental health services. Its website offers this invitation:

“We are currently seeking opportunities to bring services to areas where there is an identified need. We are looking for places where Strategic Behavioral Health can be a good provider and also a good community citizen. Please email our home office to discuss opportunities.”

Since 2006, Strategic Behavioral Health has opened centers in 11 cities, primarily in the south and west. Willow Creek Behavioral Health Center in Green Bay, which opened in January 2017, was the first site in the mid-west. According to SBH’s website, the company offers a full range of mental health and substance abuse services to just about any kind of client in need.

Funding mechanisms–the perpetual issue for mental health service providers–are less clear. SBH offers this guidance on its website.

“With payments often times being the last item patients and their families want to address, we make it a point to keep all involved parties informed while keeping the focus on treatment and recovery. Strategic Behavioral Health works with most major insurance companies and is able to work with each individual to determine the best approach for covering the cost of treatment.”

Private insurance will not cover costs for many of the people who might need a crisis restoration center or other mental health services. It is likely SBH will be competing with existing service providers for state and county funds. Let’s hope it is a “good provider and good community citizen” and that competition turns out to be a good thing.

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Maine and Virginia are getting lots of attention for their resounding support for Medicaid expansion.

By a large margin, Maine voters approved a referendum in support of expansion. Maine’s governor had vetoed legislation for the expansion five times. An estimated 70,000 to 90,000 people could gain insurance.

In Virginia, a Democratic governor had been unable to get Medicaid expansion approved by the state legislature. On Tuesday, voters elected a Democrat as governor and the party won 15 out of the 17 seats they need to take control of the state legislature. Several races were too close to call on Wednesday or require a recount.

Other news might be even more promising. In exit polls, two out of five voters in Virginia identified health as their top concern. That number was double that of any other concern mentioned.

In Utah, a political committee completed required public hearings around the state and will start gathering the signatures needed to get a Medicaid expansion question on next year’s ballot. The state’s governor and state senate had already tried to pass expansion, but failed because of the Republican controlled legislature.

Maine’s success is also encouraging efforts in Idaho for a ballot initiative on expansion. Reclaim Idaho has submitted a proposal to add the issue to the ballot for the 2018 election. The group must gather signatures from six percent of registered voters in order for the ballot initiative to move forward.

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Wisconsin’s rates have long been among the lowest in the country. The result is that mental health services are curtailed because of lack of availability of those who can afford to provide the services. See “Voices from the Front Lines: NAMI’s Lindsay Wallace” for a discussion of how the low rates affect people with mental illness in Dane County.

Gov. Walker has just announced that rates will be raised next year. According to him, they will be competitive with those in neighboring states. Click here to read the press release. Here are excerpts.

“This morning, at the 13th Annual Mental Health and Substance Use Recovery Training Conference in Wisconsin Dells, Department of Health Services Secretary Linda Seemeyer announced an investment of about $17 million, including $7 million in state funding, to raise rates for professionals providing outpatient mental health and substance use disorder services.”

“Effective January 1, 2018, Wisconsin Medicaid will increase reimbursement for outpatient mental health and substance use disorder treatment. This policy change will increase the maximum allowable fee for each covered outpatient service, and simplify the current rate structure, moving from five different fees per service to two fees per service. The new rates are competitive with border-state Medicaid programs and Medicare reimbursement, supporting growth of the Wisconsin provider workforce.”

Click here to read a story in the Milwaukee Journal Sentinel that describes reactions by advocates to the increase.

UPDATE: Wisconsin Health News provided this report about the state’s AG’s reaction to the opioid crisis.

“Attorney General Brad Schimel called for increased attention to prevention and higher reimbursement rates for addiction treatment at a Medical College of Wisconsin forum on the opioid epidemic.

‘We’re making great progress but I kind of liken this to a sinking rowboat,’ he said. ‘Law enforcement is bailing it out by arresting drug dealers. Treatment providers are bailing it out by helping people get treatment. But there’s a big hole in the bottom of the boat. And I think this is the most important piece of our efforts, it has to be the prevention side. We’ve got to get this message out to the public and to the medical community.’

Schimel also said that ‘we’re going to commit to dramatically raising the rates at which we reimburse people to provide mental health services’ and addiction treatment services to attract more workers to the field.

He and other attorneys general are putting pressure on insurers to make those changes, he said.”

“In comments submitted to DHS in mid-November, the association praised the increase. But they urged the department to add codes for psychiatrists, advanced practice psychiatric nurses and psychiatric physician assistants.

WHA general counsel Matthew Stanford wrote that the lack of codes for those professions is a “significant omission if the goal is to provide a comprehensive outpatient behavioral health reimbursement increase to address access difficulties – particularly Wisconsin’s acute shortage of psychiatrists.”

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Providers of services for children with autism are the latest group to describe the harm caused by the state’s low Medicaid reimbursement rate.

Wisconsin Health News (9/22) includes an interview with Jackie Vick and Mike Miller, the president and treasurer of the newly formed Wisconsin Autism Providers Association. One of the five goals of the WAPA is to “Increase reimbursement rates for Medicaid treatment. Low reimbursement rates are the primary cause of client demand exceeding the supply of providers…”

Miller and Vick conducted a survey to see if other providers shared the problem of “putting families in a holding pattern” because of an inability to take more Medicaid clients. The answer was “yes across the board for all of those providers.”

Miller estimated that over 500 children in the state are waiting for treatment under Medicaid funding. The lists are growing by 15 to 20 children a week and could total 1,000 by the end of the year.

Vick said that providers have responded to the challenges of the reimbursement rate in different ways. Some limited the number of Medicaid clients in order to maintain fiscal stability. A related problem, she said, is the difficulty of hiring therapists and technicians because of the low rate of pay.

She pointed out that access to treatment for young children pays off for them and for taxpayers. Vick said, “…the research shows that they make great gains and the lifetime costs of care for a child on the autism spectrum go down.”

The low Medicaid rate affects children with other behavioral health problems. Here is an excerpt from the Kids in Crisis/Legislative Action Tracker article that was part of a series by USA Today-Wisconsin (June 2016)

There is evidence that Wisconsin’s Medicaid reimbursement rates – among the lowest in the country – are shutting children out of accessing outpatient behavioral health care and leading to higher costs associated with emergency psychiatric care.

A report by Milwaukee’s Public Policy Forum found that in Milwaukee County, low reimbursement rates were stopping mental health providers from accepting Medicaid patients. A 2014 survey by the Wisconsin Statewide Medical Home Initiative found that only 20 percent of Wisconsin pediatricians said they could find therapists when needed for their patients on Medicaid, and just 5 percent could find psychiatrists for patients on Medicaid.

Check out “Voices from the Front Lines: NAMI’s Lindsay Wallace” on this blog for a report on how people with mental illness in Dane County are affected by the rate.

Click here to read a study by Pew Trusts that reports experiences of states that supplemented Medicaid rates for primary care doctors.

Lindsay Wallace, executive director of NAMI-Dane County, published a blog post that offers a good explanation of how Medicaid reimbursement rates can limit access to care for many people. She titled her article, “The Quiet Crisis in Dane County Mental Health Services.” Here it is.

“Recently, we’ve received a high volume of calls on our support line from people on Medicaid who were finding it increasingly difficult to get care. It’s not hard to imagine the frustration and sense of helplessness these individuals felt when every provider they reached out to told them they were no longer accepting Medicaid patients.

As a result of the high volume of calls we were receiving, I’ve spent the last few months meeting with community mental health providers and private practitioners to get a better understanding of why people in need of treatment and on medical assistance (MA) were being turned away.

It became evident that the issue affected individuals on straight MA, or fee-for-service, and not those served through BadgerCare HMO contracts or SSI Managed Care contracts. Under fee-for-service, qualified Medicaid providers are paid for each covered service such as a psychiatric evaluation, outpatient therapy, or targeted case management according to rates set by the state. Currently, the fee-for-service rate paid by Medicaid is, on average, about 50 cents on the dollar.

Over the years, there has been little increase in the reimbursement rate even though the cost for delivering mental health care services continues to rise. With this in mind, providers like Journey Mental Health Center (JMHC), who offers services to many MA clients, have faced significant financial losses.

Lynn Brady, CEO of JMHC, said, “In the past, we used some of the general purpose revenue (GPR) we received from the county to supplement the fee-for-service rate. However, the county has to control their costs also, and no longer allows us to do this. They are focusing county dollars on the uninsured.”

Given the toll the financial losses were taking on JMHC’s budget, they made the decision to no longer admit straight MA (fee-for-service) clients into services from their Central Intake Unit. However, this does not mean that Journey is not seeing straight MA (fee-for-service) consumers. In fact, they are seeing high numbers of them.

Lynn explained, “The difference is that now, straight MA consumers get into service here because they had a crisis and were seen in our Emergency Services Unit.”

The result of the above change? Unfortunately, rates that are not reflective of the full costs to provide services mean straight MA clients must deteriorate to a point of crisis in order to get timely access to care. We know that early intervention leads to the best outcomes but stagnant fee-for-service rates guarantee poorer access to care and sicker adults and children. This is unacceptable.

Though the county and community providers like JMHC have advocated for change, as well as many other human service providers across Wisconsin, there has been no movement in bringing about the needed changes. It appears that this is largely due to the lack of awareness on the part of policymakers about the severity of the issue. This lack of awareness may, in part, be due to the fact that unlike a sudden crisis, poorer access to care has been progressive in nature, happening slowly over time. As a result, there is little to no media coverage of the “quiet crisis”, which often serves as the catalyst for change.

So, where do we go from here?

It’s no surprise the solution is adequate mental health funding to cover the costs of delivering care; however, accomplishing that goal rests with the state. NAMI Dane County and community mental health partners and providers, and other key stakeholders can educate policymakers about the negative consequences poor reimbursement rates have on the people they believe they are covering.

Our greatest asset and most powerful tool for accomplishing this goal is to use our voices by contacting legislators and leveraging relationships with various media outlets. Power in numbers exists when policymakers hear from a large number of their constituents advocating for the policies that ensure those affected by mental illness have access to quality mental health care support and services.”

To stay up to date on this issue, sign up for action alerts at : https://www.namidanecounty.org/policy-issues/. The website for NAMI-Dane at http://www.namidanecounty.org has information about its advocacy committee and other events.

Check out the post “Low Reimbursement Rates for Medicaid Limit Access to Care” on this blog for more information.

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An article in the Milwaukee Journal Sentinel shows how an entrepreneurial approach can produce a healthy bottom line and increased access to mental health services. Click here to read “Rising need for mental health care spurs growth in Rogers Behavioral Health System.”

Rogers Behavioral Health System provides care to more than 11,000 people a year, including more than 10,000 in the Milwaukee area. In the past five years, the system’s revenue has doubled. It is continuing to expand its services and geographic reach.

Here are key excerpts from the article by Guy Boulton.

“Its recent growth stems partly from changes in federal laws that require health insurers to provide the same benefits for behavioral health as for other medical care.

It also is driven by the increasing acceptance that behavioral health conditions, such as obsessive-compulsive disorder and bipolar disorder, are no different than other medical conditions, such as diabetes or heart disease.

That has helped lessen the stigma long associated with mental illness, resulting in more people seeking treatment. More effective treatments also have contributed to the increase in demand for behavioral health care.”

Although Rogers Behavioral Health had been criticized for treating few patients covered by Medicaid, about one-third of its patients now are funded through Medicaid. It also helps fill the urgent need for in-patient psychiatric beds. An average of 500 patients a year are sent to the system when Milwaukee County’s hospital is at capacity.

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Governor Scott Walker submitted a request to the federal government for a waiver that would permit changes to the state’s Medicaid policies and requirements. Because waivers can change eligibility for benefits, federal law requires that members of the public have 30 days to register their opinions. The state must respond to concerns and may then forward the revised application to the federal government. The federal government allows another 30-day period for comment. That period ends on July 15.

More than 1,000 comments were received by the state. Less than five supported the waiver. State representatives had agreed to make all comments public as a part of its application. Instead, they were released only after the state was forced to do so because of a reporter’s request through the Open Records Act. The state had submitted only an 8-page summary of comments and its responses to them. Likely the unabridged comments depict more serious concerns and potential damage than the summary.

The state resisted notifying the public about the process for involvement or its own activities. As a result, there appears to be much less protest directed to the federal government. Nevertheless, Bobby Peterson, executive director of ABC for Health, submitted an extremely well-researched and comprehensive letter to the federal Department of Health and Human Services outlining the flaws with the waiver and the state’s process. The letter includes research results from states that have implemented variations of Wisconsin’s proposals. No state has implemented any version of drug testing as a condition for receipt of Medicaid benefits.

Click here to read the letter. Click here to enter a comment. Review the letter to develop your comments or check out “Wisconsin’s Medicaid Waiver Can Be Stopped” on this blog.

There are other ways of stopping the waiver. The legislature’s Joint Finance Committee passed a resolution stipulating that the waiver could not be implemented without its approval. We can review any version approved by the federal government, identify flaws using Peterson’s research and analysis, and begin a campaign to lobby members of the committee.

That lobbying effort could be helped by statements from Wisconsin’s own Legislative Fiscal Bureau. It has questioned whether Medicaid programs can charge premiums for people who are under the poverty level or remove them from the rolls for non-payment. It also questioned the imposition of a time limit on benefits for enrollees who have not found work.

Lobbying efforts could also remind the co-chair of the Joint Finance Committee, John Nygren, of his own more enlightened views about the best means of combatting drug abuse. Rather than punitive measures, such as testing for drugs and denying benefits, he supported the expansion of treatment options.

He and Lt. Governor Rebeca Kleefisch, co-chairs of the Governor’s Task Force on Opioid Abuse, wrote, “We’re not talking about the ‘Just Say No’ campaign of the 80’s and 90’s…As the drugs on the street have changed, our policy and policing frameworks must catch up to shifting trends.”

Peterson identified legal grounds to challenge the waiver. In particular, he pointed out court cases in which drug testing was ruled unconstitutional when used as a condition for receipt of benefits.

It appears that the entire application is a violation of the intent of the legislation. Waivers are to be “demonstrations of innovative ways to expand eligibility and Medicaid services to improve access to care and reduce costs.” State officials claim their first objective is “ensuring that every Wisconsin resident has access to affordable health insurance to reduce the state’s uninsured rate.” But, in its waiver proposal, it projects an enrollment decrease from 150,050 beneficiaries in CY 2016 to 146,407 in CY 2018.

Finally, we can always vote. This struggle could be only a painful memory when we have a different governor.

UPDATE: The League of Women Voters of Wisconsin issued an action alert with concise talking points about the hazards of the waiver and instructions about how to comment. Click here to read it.

UPDATE: Click here to read an article from USA Today, which reports comments from organizations that challenged Indiana’s request to include work requirements in its Medicaid waiver. The federal government accepted the state’s request as complete even though time for public comments had not been allowed at the state level.

UPDATE: United Health in Wisconsin submitted a letter opposing the waiver, citing continuity of care and other issues. Click here for the letter.

UPDATE: Click here for a letter from the Wisconsin Society for Addiction Medicine.

UPDATE: Click here for a story from Politico that describes the increasing importance and popularity of Medicaid. Wisconsin is out of step in its waiver request and refusal to accept Medicaid expansion funds.